Healthcare Provider Details

I. General information

NPI: 1124016936
Provider Name (Legal Business Name): HEIDI PAULINE WORLEY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 33100
APO AE
09180-3100
US

IV. Provider business mailing address

1219 APPLE ST
FAIRBORN OH
45324-3605
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-6885
  • Fax:
Mailing address:
  • Phone: 937-754-0179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: